|
HC SBBB ANTIGEN SCREENING CLASS II
|
Facility
IP
|
$115.00
|
|
|
Service Code
|
CPT 86902
|
| Hospital Charge Code |
900904769
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$20.82 |
| Max. Negotiated Rate |
$86.25 |
| Rate for Payer: Adventist Health Commercial |
$23.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$79.00
|
| Rate for Payer: Cash Price |
$51.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.86
|
| Rate for Payer: Heritage Provider Network Senior |
$77.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.75
|
| Rate for Payer: Multiplan Commercial |
$86.25
|
|
|
HC SBBB ANTIGEN SCREENING RARE
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 86902
|
| Hospital Charge Code |
900904770
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$853.31 |
| Rate for Payer: Adventist Health Commercial |
$34.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$116.79
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$673.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$494.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$449.11
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$97.50
|
| Rate for Payer: Blue Shield of California Commercial |
$105.57
|
| Rate for Payer: Blue Shield of California EPN |
$99.79
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$673.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$494.02
|
| Rate for Payer: Dignity Health Senior |
$449.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$449.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.23
|
| Rate for Payer: Heritage Provider Network Senior |
$105.23
|
| Rate for Payer: Humana Medicare |
$449.11
|
| Rate for Payer: IEHP Medi-Cal |
$5.12
|
| Rate for Payer: IEHP Medicare Advantage |
$449.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$853.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$529.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$565.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$565.88
|
| Rate for Payer: Multiplan Commercial |
$127.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$494.02
|
| Rate for Payer: TriValley Medical Group Senior |
$449.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$673.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$494.02
|
| Rate for Payer: Vantage Medical Group Senior |
$449.11
|
|
|
HC SBBB ANTIGEN SCREENING RARE
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 86902
|
| Hospital Charge Code |
900904770
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$30.77 |
| Max. Negotiated Rate |
$127.50 |
| Rate for Payer: Adventist Health Commercial |
$34.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$116.79
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$115.09
|
| Rate for Payer: Heritage Provider Network Senior |
$115.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.77
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.50
|
| Rate for Payer: Multiplan Commercial |
$127.50
|
|
|
HC SBBB AUTO ADMIN FEE
|
Facility
IP
|
$100.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900904605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.70
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
|
|
HC SBBB AUTO ADMIN FEE
|
Facility
OP
|
$100.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900904605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$53.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Blue Shield of California Commercial |
$62.10
|
| Rate for Payer: Blue Shield of California EPN |
$58.70
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: Dignity Health Senior |
$37.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.90
|
| Rate for Payer: Heritage Provider Network Senior |
$61.90
|
| Rate for Payer: Humana Medicare |
$37.20
|
| Rate for Payer: IEHP Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$70.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$46.87
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.20
|
| Rate for Payer: TriValley Medical Group Senior |
$37.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
HC SBBB CONVALESCENT PLASMA
|
Facility
IP
|
$550.00
|
|
|
Service Code
|
CPT P9059
|
| Hospital Charge Code |
900904059
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$99.55 |
| Max. Negotiated Rate |
$412.50 |
| Rate for Payer: Adventist Health Commercial |
$110.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.85
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.35
|
| Rate for Payer: Heritage Provider Network Senior |
$372.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.50
|
| Rate for Payer: Multiplan Commercial |
$412.50
|
|
|
HC SBBB CONVALESCENT PLASMA
|
Facility
OP
|
$550.00
|
|
|
Service Code
|
CPT P9059
|
| Hospital Charge Code |
900904059
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$95.16 |
| Max. Negotiated Rate |
$596.00 |
| Rate for Payer: Adventist Health Commercial |
$110.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$125.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$142.74
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$104.68
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$95.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$315.42
|
| Rate for Payer: Blue Shield of California Commercial |
$341.55
|
| Rate for Payer: Blue Shield of California EPN |
$322.85
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$357.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$142.74
|
| Rate for Payer: Dignity Health Medi-Cal |
$104.68
|
| Rate for Payer: Dignity Health Senior |
$95.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$357.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$95.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$340.45
|
| Rate for Payer: Heritage Provider Network Senior |
$340.45
|
| Rate for Payer: Humana Medicare |
$95.16
|
| Rate for Payer: IEHP Medi-Cal |
$121.57
|
| Rate for Payer: IEHP Medicare Advantage |
$95.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$180.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$112.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$119.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$119.90
|
| Rate for Payer: Multiplan Commercial |
$412.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$104.68
|
| Rate for Payer: TriValley Medical Group Senior |
$95.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$142.74
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$104.68
|
| Rate for Payer: Vantage Medical Group Senior |
$95.16
|
|
|
HC SBBB CONVLESNT PLASMA, DIVIDED
|
Facility
OP
|
$550.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900904011
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$99.55 |
| Max. Negotiated Rate |
$596.00 |
| Rate for Payer: Adventist Health Commercial |
$110.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$134.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$293.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$215.03
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$195.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$315.42
|
| Rate for Payer: Blue Shield of California Commercial |
$341.55
|
| Rate for Payer: Blue Shield of California EPN |
$322.85
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$357.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$293.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$215.03
|
| Rate for Payer: Dignity Health Senior |
$195.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$357.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$195.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$340.45
|
| Rate for Payer: Heritage Provider Network Senior |
$340.45
|
| Rate for Payer: Humana Medicare |
$195.48
|
| Rate for Payer: IEHP Medi-Cal |
$232.75
|
| Rate for Payer: IEHP Medicare Advantage |
$195.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$371.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.55
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$230.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$246.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$246.30
|
| Rate for Payer: Multiplan Commercial |
$412.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$215.03
|
| Rate for Payer: TriValley Medical Group Senior |
$195.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$293.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$215.03
|
| Rate for Payer: Vantage Medical Group Senior |
$195.48
|
|
|
HC SBBB CONVLESNT PLASMA, DIVIDED
|
Facility
IP
|
$550.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900904011
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$99.55 |
| Max. Negotiated Rate |
$412.50 |
| Rate for Payer: Adventist Health Commercial |
$110.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$377.85
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$372.35
|
| Rate for Payer: Heritage Provider Network Senior |
$372.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$99.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$137.50
|
| Rate for Payer: Multiplan Commercial |
$412.50
|
|
|
HC SBBB COOMBS DIRECT EA ANTISERA
|
Facility
IP
|
$20.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
900904733
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
|
|
HC SBBB COOMBS DIRECT EA ANTISERA
|
Facility
OP
|
$20.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
900904733
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$145.20 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$15.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$114.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$84.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$76.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$44.97
|
| Rate for Payer: Blue Shield of California Commercial |
$41.92
|
| Rate for Payer: Blue Shield of California EPN |
$32.78
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$114.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$84.06
|
| Rate for Payer: Dignity Health Senior |
$76.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$76.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Humana Medicare |
$76.42
|
| Rate for Payer: IEHP Medi-Cal |
$7.47
|
| Rate for Payer: IEHP Medicare Advantage |
$76.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$145.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$96.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$96.29
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$76.42
|
| Rate for Payer: TriValley Medical Group Senior |
$76.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$5.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$114.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$84.06
|
| Rate for Payer: Vantage Medical Group Senior |
$76.42
|
|
|
HC SBBB CROSSMATCH PER UNIT
|
Facility
OP
|
$118.00
|
|
|
Service Code
|
CPT 86920
|
| Hospital Charge Code |
900904714
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$21.36 |
| Max. Negotiated Rate |
$596.00 |
| Rate for Payer: Adventist Health Commercial |
$23.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$213.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$67.67
|
| Rate for Payer: Blue Shield of California Commercial |
$73.28
|
| Rate for Payer: Blue Shield of California EPN |
$69.27
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.75
|
| Rate for Payer: Dignity Health Senior |
$213.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.70
|
| Rate for Payer: EPIC Health Plan Medicare |
$213.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$73.04
|
| Rate for Payer: Heritage Provider Network Senior |
$73.04
|
| Rate for Payer: Humana Medicare |
$213.41
|
| Rate for Payer: IEHP Medicare Advantage |
$213.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$405.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.36
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$268.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$268.90
|
| Rate for Payer: Multiplan Commercial |
$88.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$234.75
|
| Rate for Payer: TriValley Medical Group Senior |
$213.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: Vantage Medical Group Senior |
$213.41
|
|
|
HC SBBB CROSSMATCH PER UNIT
|
Facility
IP
|
$118.00
|
|
|
Service Code
|
CPT 86920
|
| Hospital Charge Code |
900904714
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$21.36 |
| Max. Negotiated Rate |
$88.50 |
| Rate for Payer: Adventist Health Commercial |
$23.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$81.07
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$79.89
|
| Rate for Payer: Heritage Provider Network Senior |
$79.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$29.50
|
| Rate for Payer: Multiplan Commercial |
$88.50
|
|
|
HC SBBB CRYOPRECIPITATE
|
Facility
OP
|
$43.00
|
|
|
Service Code
|
CPT P9012
|
| Hospital Charge Code |
900904563
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$596.00 |
| Rate for Payer: Adventist Health Commercial |
$8.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.54
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$117.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$86.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$78.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$24.66
|
| Rate for Payer: Blue Shield of California Commercial |
$26.70
|
| Rate for Payer: Blue Shield of California EPN |
$25.24
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$27.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$86.36
|
| Rate for Payer: Dignity Health Senior |
$78.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$27.95
|
| Rate for Payer: EPIC Health Plan Medicare |
$78.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.62
|
| Rate for Payer: Heritage Provider Network Senior |
$26.62
|
| Rate for Payer: Humana Medicare |
$78.51
|
| Rate for Payer: IEHP Medi-Cal |
$64.33
|
| Rate for Payer: IEHP Medicare Advantage |
$78.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$149.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.78
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$92.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.92
|
| Rate for Payer: Multiplan Commercial |
$32.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$86.36
|
| Rate for Payer: TriValley Medical Group Senior |
$78.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$86.36
|
| Rate for Payer: Vantage Medical Group Senior |
$78.51
|
|
|
HC SBBB CRYOPRECIPITATE
|
Facility
IP
|
$43.00
|
|
|
Service Code
|
CPT P9012
|
| Hospital Charge Code |
900904563
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$7.78 |
| Max. Negotiated Rate |
$32.25 |
| Rate for Payer: Adventist Health Commercial |
$8.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$29.54
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$29.11
|
| Rate for Payer: Heritage Provider Network Senior |
$29.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.75
|
| Rate for Payer: Multiplan Commercial |
$32.25
|
|
|
HC SBBB CRYOPRECIPITATE IN POOL
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT P9012
|
| Hospital Charge Code |
900904012
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
|
|
HC SBBB CRYOPRECIPITATE IN POOL
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT P9012
|
| Hospital Charge Code |
900904012
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$596.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$54.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$117.76
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$86.36
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$78.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$68.82
|
| Rate for Payer: Blue Shield of California Commercial |
$74.52
|
| Rate for Payer: Blue Shield of California EPN |
$70.44
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$117.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$86.36
|
| Rate for Payer: Dignity Health Senior |
$78.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$78.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.28
|
| Rate for Payer: Heritage Provider Network Senior |
$74.28
|
| Rate for Payer: Humana Medicare |
$78.51
|
| Rate for Payer: IEHP Medi-Cal |
$64.33
|
| Rate for Payer: IEHP Medicare Advantage |
$78.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$149.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$92.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$98.92
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$98.92
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$86.36
|
| Rate for Payer: TriValley Medical Group Senior |
$78.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$596.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$501.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$117.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$86.36
|
| Rate for Payer: Vantage Medical Group Senior |
$78.51
|
|
|
HC SBBB DD ADMIN FEE
|
Facility
OP
|
$145.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900904780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Adventist Health Commercial |
$29.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$77.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$99.62
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Blue Shield of California Commercial |
$90.04
|
| Rate for Payer: Blue Shield of California EPN |
$85.12
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$94.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: Dignity Health Senior |
$37.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$94.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$89.76
|
| Rate for Payer: Heritage Provider Network Senior |
$89.76
|
| Rate for Payer: Humana Medicare |
$37.20
|
| Rate for Payer: IEHP Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$70.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.24
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$46.87
|
| Rate for Payer: Multiplan Commercial |
$108.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.20
|
| Rate for Payer: TriValley Medical Group Senior |
$37.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
HC SBBB DD ADMIN FEE
|
Facility
IP
|
$145.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900904780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.24 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Adventist Health Commercial |
$29.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$99.62
|
| Rate for Payer: Cash Price |
$65.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$98.16
|
| Rate for Payer: Heritage Provider Network Senior |
$98.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$26.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$36.25
|
| Rate for Payer: Multiplan Commercial |
$108.75
|
|
|
HC SBBB DIFF ADSORP
|
Facility
IP
|
$95.00
|
|
|
Service Code
|
CPT 86978
|
| Hospital Charge Code |
900904741
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$71.25 |
| Rate for Payer: Adventist Health Commercial |
$19.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.26
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$64.32
|
| Rate for Payer: Heritage Provider Network Senior |
$64.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.75
|
| Rate for Payer: Multiplan Commercial |
$71.25
|
|
|
HC SBBB DIFF ADSORP
|
Facility
OP
|
$95.00
|
|
|
Service Code
|
CPT 86978
|
| Hospital Charge Code |
900904741
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$150.63 |
| Rate for Payer: Adventist Health Commercial |
$19.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$65.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$114.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$84.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$76.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.63
|
| Rate for Payer: Blue Shield of California Commercial |
$59.00
|
| Rate for Payer: Blue Shield of California EPN |
$55.76
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Cash Price |
$42.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$114.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$84.06
|
| Rate for Payer: Dignity Health Senior |
$76.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$61.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$76.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.80
|
| Rate for Payer: Heritage Provider Network Senior |
$58.80
|
| Rate for Payer: Humana Medicare |
$76.42
|
| Rate for Payer: IEHP Medi-Cal |
$31.15
|
| Rate for Payer: IEHP Medicare Advantage |
$76.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$145.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$90.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$96.29
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$96.29
|
| Rate for Payer: Multiplan Commercial |
$71.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$76.42
|
| Rate for Payer: TriValley Medical Group Senior |
$76.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$114.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$84.06
|
| Rate for Payer: Vantage Medical Group Senior |
$76.42
|
|
|
HC SBBB DILUTION
|
Facility
IP
|
$30.00
|
|
|
Service Code
|
CPT 86976
|
| Hospital Charge Code |
900904738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SBBB DILUTION
|
Facility
OP
|
$30.00
|
|
|
Service Code
|
CPT 86976
|
| Hospital Charge Code |
900904738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$120.53 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$37.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$120.53
|
| Rate for Payer: Blue Shield of California Commercial |
$18.63
|
| Rate for Payer: Blue Shield of California EPN |
$17.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.80
|
| Rate for Payer: Dignity Health Medi-Cal |
$40.92
|
| Rate for Payer: Dignity Health Senior |
$37.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$37.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Humana Medicare |
$37.20
|
| Rate for Payer: IEHP Medi-Cal |
$25.97
|
| Rate for Payer: IEHP Medicare Advantage |
$37.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$70.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$43.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$46.87
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$46.87
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$37.20
|
| Rate for Payer: TriValley Medical Group Senior |
$37.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$55.80
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$40.92
|
| Rate for Payer: Vantage Medical Group Senior |
$37.20
|
|
|
HC SBBB ELUTION
|
Facility
OP
|
$70.00
|
|
|
Service Code
|
CPT 86860
|
| Hospital Charge Code |
900904735
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.67 |
| Max. Negotiated Rate |
$405.48 |
| Rate for Payer: Adventist Health Commercial |
$14.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$46.94
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$213.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$225.97
|
| Rate for Payer: Blue Shield of California Commercial |
$43.47
|
| Rate for Payer: Blue Shield of California EPN |
$41.09
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$320.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$234.75
|
| Rate for Payer: Dignity Health Senior |
$213.41
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$213.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.33
|
| Rate for Payer: Heritage Provider Network Senior |
$43.33
|
| Rate for Payer: Humana Medicare |
$213.41
|
| Rate for Payer: IEHP Medi-Cal |
$30.93
|
| Rate for Payer: IEHP Medicare Advantage |
$213.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$405.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.67
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$251.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$268.90
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$268.90
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$213.41
|
| Rate for Payer: TriValley Medical Group Senior |
$213.41
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$320.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$234.75
|
| Rate for Payer: Vantage Medical Group Senior |
$213.41
|
|
|
HC SBBB ELUTION
|
Facility
IP
|
$70.00
|
|
|
Service Code
|
CPT 86860
|
| Hospital Charge Code |
900904735
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.67 |
| Max. Negotiated Rate |
$52.50 |
| Rate for Payer: Adventist Health Commercial |
$14.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.09
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.39
|
| Rate for Payer: Heritage Provider Network Senior |
$47.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.67
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.50
|
| Rate for Payer: Multiplan Commercial |
$52.50
|
|
